Trochanteric bursitis is a clinical diagnosis that consists of inflammation of the bursa located at the greater trochanter of the femur. A bursa is a small, fluid filled sac that develops between structures in areas in the body where there is excessive movement causing friction between associated structures8. These bursae develop to minimize this friction between frequently moving structures to have greater ease of movements. The bursa associated with trochanteric bursitis is located between the greater trochanter and tendons of surrounding musculature, including the gluteal muscles. These bursae can often be irritated with repetitive movements, especially on inclined surfaces such as hills or stairs, or by acute trauma. Irritation of the bursa causes pain. The pain associated with trochanteric bursitis can be described as deep, dull, burning pain or tightness on the lateral aspect of the hip around area of the greater trochanter. This pain and discomfort can often spread down the lateral aspect of the thigh, but rarely spreads to the knee or distal to the knee11. If identified in the acute stages of symptoms, trochanteric bursitis can be relatively easily managed by addressing the aggravating factors. More chronic cases of trochanteric bursitis tend to be more complicated to treat.
More recent literature refers to trochanteric bursitis as greater trochanteric pain syndrome (GTPS). This is partially because some of the cardinal signs of inflammation such as redness, swelling and heat are not typically present with “trochanteric bursitis.” Silva, et al. found that there were no significant findings of signs of inflammation in dissected bursae that were thought to be inflamed. Also, as imaging studies become more sophisticated, the source causing the pain of trochanteric bursitis can originate from surrounding structures other than the bursae themselves, for example, abnormal construction or damage to hip abductor tendons.
The greater trochanter is located proximally and laterally on the femur, just distal to the hip joint and the neck of the femur. On this bony prominence attach tendons of the gluteus maximus, medius and minimus muscles, tensor fasciae latae (TFL) muscle, some fibers of the vastus lateralis muscle and the ilio-tibial band (IT band). In anatomic and imaging studies, three major bursae can be identified as consistently present11. The subgluteus medius bursa was found to be located laterally and superiorly on the greater trochanter, just deep to the tendon of the gluteus medius muscle16. The subgluteus minimus bursa was found to be anterior and medial along the greater trochanter, deep to the superior aspect of the gluteus minimus muscle insertion. And the trochanteric bursa (or subgluteus maximus bursa) is described as being along the lateral aspect of the greater trochanter and covering the lateral insertion of the gluteus medius muscle13. This large bursa is also associated with the fibers of the TFL and vastus lateralis muscles as well as the IT band.
III. Incidence/ Prevalence
GTPS is a common clinical diagnosis and is recorded to be present in about 1.8 in 1000 primary care patients6.
- GTPS presents more frequently in women than men, with women representing 80% of trochanteric bursitis cases. With this higher incidence in women, it has been inferred there lower extremity biomechanics may contribute to GTPS6. Recorded incidence for unilateral trochanteric bursitis is 15% in women and 6.6% in men; the bilateral incidence of trochanteric bursitis is 8.5% in women and 1.9% in men6.
- There were no recorded differences based on age, race, BMI or reported activity level; although most etiological investigations have occurred in adult populations.
- Long distance runners, or other athletes who engage in repetitive motions of the lower extremities, tend to have a higher incidence of GTPS.
Image from: http://www.cyberpt.com/images/hipbursa.jpg
IV. Potential Etiologies (risk/causative factors)
Some of the factors that have been shown to contribute to the development of trochanteric bursitis are:
1) IT band pathology (repetitive stress/overuse trauma)
- The iliotibial (IT) band receives fibrous contribution from the gluteus maximus, tensor fasciae latae, and vastus lateralis muscles and runs over the greater trochanter. Therefore, tightness in this structure, from overuse, can irritate and inflame the bursae associated with the gluteal tendons surrounding the greater trochanter.
- The overuse and tightness of the IT band can come from high mileage sporting activities or contact sports. During these instances, the muscles contributing to the IT band are greatly used or there is a higher chance of acute trauma to the greater trochanter. Running along hills or embankments can also contribute to this pathology as it creates a temporary, functional leg length discrepancy10.
2) Abductor tendon pathology
- Pathology involving the hip abductor tendons is one of the more recent causes that is suggested to contribute to GTPS. In an MRI study by Bird, et al. subjects with “trochanteric bursitis” were examined on MRI2 and through clinical tests. The most common defect found on MRI contributing to the subjects’ pain was a tear or inflammation in the gluteus medius tendon, this held a strong correlation with the presence of a Trendelenburg sign in the affected hip.
3) Complication of lateral hip arthroscopy or THR
- In a study performed by Farmer, et al., examining the outcomes of hip arthroplasties4, the incidence of trochanteric bursitis as a complication to total hip arthroplasty was found in 1.4% of cases. The majority of these cases did see symptom resolution after further conservative treatment.
4) Acute trauma (falls), Lower Extremity Biomechanics, and hip abductor muscle weakness have also been documented as common etiological factors in trochanteric bursitis.
V. Clinical Presentation
Pain and tenderness over the lateral aspect of the thigh is the chief complaint of patients presenting with GTPS. This pain has been documented to radiate down the thigh and lower buttocks, but rarely travels to the posterior thigh or distal to the knee. The pain associated with GTPS can be described as aching, but intense at times of greater aggravation. Localized tenderness will also be found at the area of the greater trochanter as well as aggravation with passive, active, and resisted hip abduction and external rotation11. Because trochanteric bursitis is often triggered by repetitive motions, climbing stairs or hills, running or walking long distances or side-lying on the affected hip may increase patients symptoms.
There are a number of conditions that a patient may present with in addition to symptoms of GTPS. It is unknown, however, if these cause GTPS or simply have an affect on the symptoms of GTPS. These conditions include:
- Ipsilateral or contralateral degenerative hip disease
- Leg-length discrepancy
- Iliotibial band syndrome
- Iliopsoas tendon pathology or “snapping hip” syndrome
- Total hip arthroplasty
- Other medical conditions such as thyroid disease, gout or rheumatoid arthritis
- Residual weakness of thigh and hip muscles following hip or back surgery
- Pes planus
- Lower leg amputation
- Chronic low back pain
- Tendon pathologies of the hip external rotators or abductors
- Degenerative joint disease of the knee
VI. Differential Diagnosis
Because lateral hip pain is a fairly common component of many low back and lower extremity pathology, a differential diagnosis must rule out other disorders. Some of the most common disorders that are ruled out during the clinical diagnosis of trochanteric bursitis are: femoral head avascular necrosis, hip fracture, iliopsoas tendinitis, IT band syndrome, osteoarthritis of the hip and lumbar spine radiculopathy14.
Bierma-Zeinstra, et al. began constructing a “cluster analysis” method1 of categorizing hip disorders due to the lack of valid classification and diagnostic systems in existence for conditions of the hip. Reliability was found, but without a gold standard, validity could not be accurately assessed. Subjects who had previously tested positive for greater trochanteric pain syndrome clustered into the following symptoms: pain with palpation to the lateral thigh, and weakness in resisted hip abduction and internal rotation.
In an MRI diagnostic by Blankenbaker, et al., T2 weighted MRI images were used to correlate previous clinical diagnoses of trochanteric bursitis with findings on the imaging performed3. Previous clinical diagnoses were corroborated by MRI evidence of peritrochanteric edema or the presence of some gluteal tendon pathology.
Jones et al., presented a case of a patient who was diagnosed and treated for trochanteric bursitis with little success20. It was discovered that the patient had pain with palpation deep to the greater trochanter and a non-capsular pattern of pain and resistance provocation. Further diagnostic investigation revealed a stress fracture of the femoral neck and proper treatment followed. This case points to the importance of proper clinical differential diagnosis of trochanteric bursitis.
|Differential Diagnosis of Common Hip Pain Issues14|
IT band / GTB
- Patients typically complain of lateral thigh pain over the GT and difficulty lying on their side.
- Physical exam shows a positive ober's test (pain), snapping with moving the hip between flexion and extension or internal rotation and external rotation.
- Gold standard for diagnosis is a small field MRI.
Glut min/med injury
- Patient typically presents with dull posterior/lateral hip pain.
- Physical exam usually shows focal tenderness on the gluteal insertion and weak hip abduction. Exam may also show pain with passive and resisted internal rotation with hip flexed to 90 and SLS for 30 or more seconds.
- MRI may be used to detect partial versus complete tears.
- Patient usually complains of exercise-induced pain in the hip, groin, or thigh.
- Radiographs are common for diagnosis but MRI and bone scan are more sensitive.
- Patient typically presents with aching groin or medial thigh pain.
- Physical exam usually shows tenderness with palpation and focal swelling along the adductors Patients also experience decreased strength with resisted adduction.
- MRI can be used to detect tears.
- Patients will typically describe pain around the SIJ and sciatic notch.
- Physical exam usually experience pain with palpation at the sciatic notch or greater trochanter.
- MRI may show Piriformis muscle atrophy or hypertrophy and edema surrounding the sciatic nerve.
Sacroiliac Joint Pain
- Patients typically complain of buttock pain that may radiate to the thigh.
- Physical exam usually reveals tenderness along the SIJ or sacral sulcus.
- CT scan, MRI, and Bone Scan can be used to identify possible SIJ dysfunction etiologies.
- Patients usually complain of insidious onset of pain associated with activity, which resolves with rest. The pain may also radiate into the adductors, perineum, rectus, or testicular areas.
- Physical exam usually reveals pain with inguinal palpation, coughing, and sneezing.
- Differential diagnosis is needed diagnosis of this issue. MRI, radiographs, ultrasounds, or bone graphs may all be used to rule out other causes of hip pain.
- Patients typically complain of sharp or anterior pelvic pain over the pubic symphysis, which may radiate into lower abdominal muscles, perineum, or thigh adductors.
- Physical exam usually reveals tenderness with palpation over the pubic rami, pubic symphysis, and with adductor stretching.
- Bone scan and MRI have been shown to be effective in diagnosing osteitis pubis.14
VII. Evaluation/Special Orthopedic Tests
Throughout the evaluation of a patient presenting with GTPS, there are several positive findings that can reinforce this clinical diagnosis.
Special Tests which clearly support GTPS diagnosis:
- Tenderness to palpation on the lateral aspect of the hip
- Pain with passive internal rotation 25
- Reproduction of symptoms with resisted hip abduction24.
Other Special Tests:
- Trendelenburg sign: This single leg stance test evaluates the eccentric control of the gluteus medius muscle in its role of stabilizing the hip and pelvis. This was found to be a reliable measure in detecting gluteus medius muscle tears as a contributor to greater trochanteric pain syndrome with a sensitivity of 72.7% and specificity of 76.9%2. A positive sign during this test is a drop of the pelvis contralateral to the stance leg - demonstrating weakness of the ipsilateral hip abductors.
- FABER (flexion, abduction, external rotation) test: The patient will be supine and passively placed into unilateral hip flexion, abduction and external rotation to test symptom provocation. (As seen in the image to the right.) A positive for this test is pain reproduction through the anterior hip. If the test results in pain in the posterior hip, this may be indicative of an SI issue.
- Ober’s test for IT band tightness: For this test, the patient will be in side-lying with the involved side up. The top hip will be extended and the limb lowered to test for IT band tightness as a contributor to GTPS. A positive sign will be if the top leg does not fall below parallel to the table.
- Considering that low back pain with progression of pain to the lateral aspect of the hip may also be associated with trochanteric bursitis, the back should be ruled out as a possible cause through the use of clearing tests. The lumbar spine should be cleared by taking patient through ROM then applying overpressure at the end of range.
- The knee should also be cleared as a possible cause by using ROM and overpressure.
VIII. Conservative Treatment
Conservative treatment for trochanteric bursitis can include physical therapy, anti-inflammatory medications or corticosteroid injections.
In the case of an overuse injury or leg-length discrepancy, the adjustments can be relatively straightforward. Some cases of trochanteric bursitis can arise from pre-existing conditions such as osteoarthritis of the hip or knee, those cases may be more involved and complicated to treat. Before beginning treatment, it is important to know the phases of healing so that optimal conditions can be created in order for the tissue to heal as quickly and properly as possible.
Stages of Healing
In order for soft tissue to be repaired, four main stages of healing must occur: hemostasis, inflammation, proliferation, and remodeling.22 Hemostasis begins immediately after injury within seconds and can last up to a few hours.23 Blood-borne cells, proteins, and platelets are released outside of the tissue.23 This stage also includes vascular constriction and the formation of fibrin clots.22 The tissue then releases different growth factors to initiate the next phase, inflammation.22
The inflammation phase begins after a few hours and can last 2 or 3 days.23 Neutrophils begin to migrate toward the injured area in order to clear cellular debris.22,23 Next, macrophages rid the tissue of apoptotic cells to pave the way for the third phase, proliferation.22
Cellular proliferation begins within days and can last up to a few weeks.23 During this stage, epithelial cells reproduce over the injured tissue to promote collagen and granular tissue formation.22 Later in this phase, the extracellular matrix (ECM) is formed.22
The final phase of remodeling begins within weeks and can last for several months or even years.22,23 Cross links are formed by collagen tissue and scar tissue is created.23
Physical therapy programs aim to find and correct the source of the injurious process so the patient can improve their quality of life7. The primary goal of the PT intervention is to calm the area of inflammation or irritation in the hip and allow for the inflammatory process to clear.
This will include measures such as:
- Rest (this may include cross-training for athletes)
- Activity Modifications (may include use of assistive devices)
- Cryotherapy (ice packs)
- Iontophoresis or Phonophoresis21
- Transcutaneous Electrical Nerve Stimulation (TENS)
- Soft Tissue Mobilization
Once the irritation has subsided, the next goals are to improve flexibility and strength of the affected hip to prevent the recurrence of irritation of the greater trochanter. Restoring a strong biomechanical balance in the hip joint will create a greater likelihood that the bursitis will not return. This will mean gaining appropriate range of motion and strength in the muscles surrounding the hip joint. Targeted tissues will include: TFL muscle, IT band, vastus lateralis muscle, gluteus medius muscle and gluteus maximus muscle.
Some activities that may be included in physical therapy are:
- Passive and active range of motion exercises
- Flexibility and stretching training
- Progressive hip stabilization exercises
- Orthotics to correct harmful foot/gait disturbances
Image from: http://somethinggoodgoingtohappen.files.wordpress.com/2010/04/xtrochan.jpg?w=231&h=300&h=300
Currently there is very little research regarding physical therapy treatment of trochanteric bursitis. While there is substantial research regarding manual therapy of patients with osteoarthritis of the hip that may presumably carry over into the deficits found in trochanteric bursitis, evidence supporting or negating efficacy of manual therapy in this pathology is sparse. A literature search revealed that the only current research on the benefits of manual therapy in the treatment of trochanteric bursitis was a case report performed at Carroll University. The patient presented with signs and symptoms of trochanteric bursitis, as well as hypomobility in posterior, lateral, and inferior directions. After receiving Grades I-III joint mobilizations in all of these directions prior to exercise for 6 sessions patient-reported improvement was noted in pain levels, weight-bearing, walking, and activity tolerance. Gains were also noted in hip abduction strength of the involved limb15a.
While this case report shows promise in the benefits of manual therapy in the treatment of trochanteric bursitis, it is clear that more research is required to expand knowledge in this area.
Although the presence of frank inflammation is questioned, the presence of irritation is undoubted. Some people may benefit from the use of over-the-counter anti-inflammatory medications such as ibuprofen or naproxen sodium. The next line of anti-inflammatory pharmaceutical action are corticosteroid injections directly into the trochanteric bursa5.
These injections are effective in providing symptom relief in many patients and usually are administered in a series of three, with one every 3-4 weeks. These periods of symptom relief can be beneficial enough to
- break the pain cycle
- allow for periods of strengthening and stretching and
- correcting any lower extremity biomechanics to remove the irritating force on the greater trochanter.
Kelly et al., advocates the use of injections for trochanteric bursitis treatment5 with a return treatment in 1-2 years. However, in 2009 Rompe et al.17, found that the benefit of corticosteroid injections declined after one month and the benefits of a home therapy program continued after four and fifteen months. As frequently as corticosteroid injections are used for this condition, the long-term benefits may not cover the cost of the treatment to the patient.
IX. Surgery & Post-Op Treatment
When conservative treatments are not effective and lateral hip pain still persists, there are surgical measures that can be taken.
One option is removal of the problematic bursa, or a bursectomy. This can be performed as an open surgery, but it is now most commonly done arthroscopically. The arthroscopic procedure is referred to as a bursectomy with IT band release. During this procedure, the fascia latae, which lies over the greater trochanter, is split to access the bursa underneath. This split of the muscle and fascial tissue releases of tension on the IT band that may contribute to symptoms in GTPS. After the fascia latae is split, the inflamed bursa is removed, thus removing a major source of inflammation and pain generation in the hip9.
Image from: http://www.eorthopod.com/images/ContentImages/hip/hip_bursectomy/hip_bursectomy_surgery05.jpg
After the bursa has been removed, the tendons of the vastus lateralis and gluteus medius muscles can be visualized and examined for damage. At this time, subsequent repairs to surrounding tissues can be made, if necessary15. Because bursae develop in places of friction in the body, a new bursa will develop in the place of the inflamed bursa that has been removed. But with the IT band release and other repairs that were made at the time of surgery and biomechanical corrections made in post-operative physical therapy, inflammation in the new bursa should not develop.
- In 2002, Fox followed patients who opted to undergo a bursectomy after conservative treatments of corticosteroid injections were not effective in eliminating lateral hip pain18. Of the 27 subjects included in this study, only two subjects experienced recurrences of pain in the five years following the procedure.
- In 2007, Baker et al., tracked the progress of 25 patients for 1-2 years after arthroscopic bursectomy procedures and all subjects improved on scores of function and pain19. This investigation also found that the improvements made 1-3 months after the surgery were equal to those improvements measures farther out after the surgical procedure. Surgery for recalcitrant cases of trochanteric bursitis has proved to be effective and safe, providing excellent results for those who did not respond to conservative treatments.
Physical therapy treatment after arthroscopic greater trochanteric bursectomy and IT band release begins early as patients are encouraged to weight-bear the same day as the surgery, using axillary crutches only for comfort in the first week post-op. Some important things to note:
- Range of motion activity within comfortable active ranges for the patient is encouraged as soon as possible after the surgery
- No movement restrictions on the operative hip following this surgical procedure
- Physical therapy will then commence focusing on strengthening, stretching, and correcting any lower extremity biomechanical imbalances.
X. Additional Web Based Resources
To guide further investigation…
Evaluating hip pathology in trochanteric pain syndrome Medpedia
Hip Bursitis Injury Explained Physioroom
Trochanteric Bursitis Physioadvisor
Medscape Trochanteric Bursitis
Medscape Physical Medicine and Rehabilitation for Trochanteric Bursitis
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